Provider Demographics
NPI:1710379342
Name:GONZALES, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GONZALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7403 DAUGHERTY ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2121
Mailing Address - Country:US
Mailing Address - Phone:512-934-3536
Mailing Address - Fax:866-886-5800
Practice Address - Street 1:1101 W 34TH ST
Practice Address - Street 2:SUITE 635
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1907
Practice Address - Country:US
Practice Address - Phone:512-934-3536
Practice Address - Fax:866-886-5800
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10012712081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
473092812OtherEIN